Understanding nocturnists

Most hospitalist programs misunderstand how to attract and keep quality physicians in this role, the author says.

Another hospitalist recently observed to me that the pool of potential nocturnists was “a weird bunch of people.” Having worked as a nocturnist myself for 5 years, I think the flaw lies not in the physicians but in their management. Most hospitalist programs misunderstand how to attract and keep quality physicians as nocturnists.

Although I'm sure that there are programs out there that do it well, it seems like most programs that hire nocturnists have them working schedules that are unsustainable, with a poor understanding of how to help them thrive in these positions. A nocturnist friend said, “They schedule me as if I were a regular day person doing 1 night at a time, not as a night person who has to do this over and over.” Hospitalist programs fail to see nocturnist positions as something that needs special management.

The end result is disinterest in nocturnist jobs by most hospitalists, so nocturnist positions remain a difficult recruit for most programs. This should indicate to leadership that there's something wrong with both how we structure these jobs and how we treat individuals working them. I have personally found that working nights has enabled me to have flexibility for my family that is enviable compared to just about any other physician specialty, in addition to being professionally and financially rewarding.

Exclusive night-shift work does have special challenges, centered around the ability of an individual to work counter to circadian rhythms, with implications for job satisfaction, health, and the quality of work performed at night. But there is a body of literature regarding best practices for night-shift work in other industries that seems to be mostly ignored by hospitalist programs. I think widespread adoption of a different approach to night shifts could grow the pool of hospitalists attracted to this niche and improve professional satisfaction in hospitalist groups as well as the quality of care delivered.

My (weakly) evidence-based tips for managing nocturnists:

  • Ditch 7-on/7-off. My own experience working nights (usually 3 to 5 at a time) and literature from other industries suggests we could create more sustainable nocturnist programs by having people working fewer shifts. Some programs appear to already be doing this, according to Society of Hospital Medicine and AMGA surveys, which suggest that some nocturnists are considered full-time at only about 12 shifts per month. In my opinion, the only programs that are probably safe with 7-on/7-off schedules and high numbers of shifts per month are lower volume.
  • Avoid morning meetings. Think twice before scheduling meetings that nocturnists need to attend in the morning after they've worked the night. An exception to this might be if the nocturnist is about to be off for multiple days and is adjusting back to spending the day awake.
  • Streamline signout. Although this runs counter to practice at many busy programs, protracted signout processes that keep nocturnists at work after dawn likely contribute to degraded sleep quality. I believe electronic signout should be the norm, except in cases of ongoing clinical urgency. In our practice, we leave voicemail on routine cases but may call the oncoming hospitalist about a patient just transferred to the ICU who needs attention.
  • Keep shifts shorter. Avoid scheduling 12-hour night shifts at busy facilities. Longer night shifts probably contribute to worse sleep and performance. In my program, nocturnists work 8 p.m. to 6 a.m. on weeknights. Purely from a sleep quality standpoint, shift turnover at or before dawn is desirable.
  • Promote nonclinical roles. Nocturnists should participate in nonclinical roles within hospitalist groups to help keep them integrated into group/local medical culture, including committee membership, schedule management, and leadership activities. The bright side of my night schedule is that I'm available to actively participate in a meeting during the day when standard working hospitalists might have to deal with their pagers.
  • Allow an adjustment period. Ideally, nocturnists should have a reasonably long period of integration/orientation to the hospitalist group before they take on a nights-only role. Several months of day shifts will make them familiar to team members as well as the larger medical community prior to being isolated on nights. In my opinion, many groups would do better to develop nocturnists internally rather than recruiting a night-only physician from outside of the community.

Nocturnists can do their part, too, in making the job more comfortable and successful. My tips for them:

  • Don't take more than 7 shifts in a row. It is debatable from the literature on shift-work safety whether we should allow ourselves any prolonged strings of consecutive nights, given the cumulative sleep deficits and worsened cognitive performance that seems to go along with this. I have seen nocturnists pull 9 consecutive nights “to just lump them together” and come out as doctor-zombies by the end.
  • Avoid caffeine in the last 6 hours of your shift. Caffeine can disrupt sleep beyond the period of time where we perceive ourselves to be stimulated.
  • Shun the sun. Avoid long commutes home in the morning and exposure to bright sunlight. Light is a strong entrainment stimulus to the circadian rhythm. Ideally, be in bed at dawn, or wear sunglasses on your way home.
  • Make use of melatonin. When shifting back to days, melatonin can be very helpful: 1 to 3 mg at 9 p.m. on your first 2 to 3 nights off can readjust your circadian rhythm. After a couple of years of taking zolpidem and still waking up at 3 a.m. in the middle of my week off, I've found that melatonin works much better for me. There is good evidence that melatonin works for improving sleep for jet lag, despite the lack of standardization in its manufacture as a supplement. I have also seen mention of melatonin to aid in daytime sleep, but in my anecdotal discussions with other night workers, it seems to be more commonly used to flip back to nighttime sleep on days off.
  • Take a nap—but not during your shift. A 60- to 90-minute nap prior to starting your night shift may improve alertness and sense of well-being at the start of your shift. But avoid napping during your night shift, especially if doing multiple consecutive nights; this is likely to actually hamper daytime sleep.
  • Avoid eating after midnight. Even after acclimation to nights, eating late will degrade sleep in the morning hours. Gastrointestinal function has a strong circadian variability.
  • Keep things dark. Use window blackout shades or eye shades as well as ear plugs/white noise to sleep in the morning. Go right to bed on arrival home, preferably when it's still dark. Sleep at cooler ambient temperatures, which can help diminish risk of arousal.
  • Stick to a schedule. Avoid the temptation to frequently interrupt sleep on work cycles to meet social/family obligations. I try to look at afternoons after waking as “what one major productive thing could I get done today?”

Night shifts are among many things that hospital medicine, being a relatively young specialty, has yet to figure out how to do the best possible way. Working nights has long been seen as a hardship, with even physicians in the field believing it is about working a difficult schedule at higher wages for a short period, rather than a sustainable practice. But it could be a more attractive career niche if we're able to change a few things about how we manage ourselves, and how we adapt to being part-time night creatures.